Healthcare Provider Details

I. General information

NPI: 1952265936
Provider Name (Legal Business Name): GRACEFUL LIFE HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1536 ANDERSON ST
GASTONIA NC
28054-1223
US

IV. Provider business mailing address

15135 ALIJON CT
CHARLOTTE NC
28278-6885
US

V. Phone/Fax

Practice location:
  • Phone: 917-341-3659
  • Fax:
Mailing address:
  • Phone: 917-341-3659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JEANETTE RODRIGUEZ
Title or Position: OWNER
Credential:
Phone: 917-341-3659